I have made many long-standing complaints about the appropriateness and the overall suitability of the British Casting Certificate (BCC) cast technician's course; aka The Theory and Practice of Musculoskeletal Casting and Splinting (TPMCS).
My last formal attempt at improving the unsatisfactory work which I had seen around the UK was made to the British Orthopaedic Association Casting Committee Chair in 2013; where it was largely ignored by the BOACC. It may be helpful to the leaders of the cast technician fraternity to gain an insight into what an appropriate course of instruction ought to include and which areas of training it should seek to address.
Comparing the UK course of instruction with the currently available instruction in other developed countries (USA, Canada & Australia) we can see that the just five weeks duration taught components of the TPMCS does not compare favourably with the much longer taught courses in North America and Australia.
The casting professional title in the USA is Orthopaedic Technologist. There is a national certification scheme run by the The National Board for Certification of Orthopaedic Technologists. The body which provides professional support to orthopaedic technologists in the USA is the National Association of Orthopaedic Technologists. It is clear from the materials provided on the NAOT site that a minimum of two years orthopaedic experience and science knowledge is recommended before a course of study is undertaken.
The Canadian Society of Orthopaedic Technologists (CSOT) oversees all matters pertinent to orthopaedic technologists (cast technicians) in Canada. The Scope of Practice indicates how well developed this society is. Here is an example 300 question rounds quiz questionnaire, for which all Canadian orthopaedic technologists would be expected to answer the majority of questions correctly.
It is quite clear, when looking at the question sheet to which I have linked, that many of the questions would be beyond the current knowledge of TPMCS holders in the UK. This lack of knowledge underpins why the TPMCS course is not fit for purpose. It is obvious that a minimum two year taught course would be necessary to impart the CSOT course knowledge to a trainee cast technician.
Additionally, a two year timetable would enable the course tutors of any analogue of the CSOT course; to pass sufficient information to the trainee cast technician, in order to permit them to work as a qualified orthopaedic technician on gaining the certificate.
These linked pages detail some exam questions and answers for the candidate wishing to undertake the CSOT examination for orthopaedic technologists. The final examination content and its associated marking system is laid out in the following pages of the CSOT website. Finally, this page links to the ethics which binds Canadian orthopaedic technologists.
The requirement to work for at least eight years in Canada, before being considered eligible to undertake a course of instruction for an advanced orthopaedic technologist, is necessary because of the theoretical knowledge and practical experience required to successfully complete the course.
There is no comparable course of instruction in the UK. Cast technicians may attend a refresher course for the application of casts but that is all. There are no advanced or further courses with which the TPMCS certificated cast technician can update their skills and knowledge or learn about new methods.
The Australian Government oversee the certificate IV in cast technology. The certificate takes a minimum of two years to gain and the component competencies can be viewed at the following link. Competency based tuition implies that an amount of material must be taught and assimilated before a trainee is assessed as having sufficient skill to have been deemed to pass a specific point in their training. Two years work is the minimum required for the very skilled work of a cast technician.
Candidates for the UK casting course are expected to have worked in a cast room for up to two years (unsupervised by the tuition staff at RNOH or BRI) before undertaking the taught components. A single year (or even much less) of cast room experience was considered to be sufficient in several cases which are known to me personally.
Because the cast technician candidates are usually drawn from the HCAs working in the outpatient clinic environment, they are often detailed to do 'much more important' clinic work by the senior manager. They do not appear to receive sufficient practical experience or 'hands on' time to spend in the cast room environment.
The practical skills required to apply a cast could be taught in a relatively short period of time. I estimate that I could teach sufficient technique, knowledge and skill within one week, to any person who was required to apply a plaster of Paris (POP) temporary splint to an injured limb.
Teaching circumferential casting techniques would be possible within another one week. The mechanical skill is a simple task to teach. The work of a cast technician requires far more than the application of mechanical skill. It is the case that the primary focus of the TPMCS course is teaching just the practical skill of casting. The final course assessment bears mute witness to this unbalanced emphasis on mechanical casting prowess.
Moving from the current inadequate position (imparting information which does not equip new cast technicians with sufficient knowledge to complete the work in a clinically rational manner) to a new position, will take some effort. Every newly certificated cast technician should be a capable and professional member of the multi-disciplinary orthopaedic team. This movement would require a sea-change in approach from our leaders and a concomitant examination of the work one expects the cast technician to be able to complete.
The clinical significance of casting and splinting work is not in doubt. Patients may well be harmed by poorly completed work. It should be the case that every treating lead clinician should know what to expect from their local cast technicians. Lead clinicians could then plan a course of treatment and know that the patient will be well-served by their treatment plans and that the objectives of the prescribed treatment will be met.
Relying on a cast technician to deliver any particular treatment plan objectives may lead to a failed treatment, where the cast technician is unaware of their own lack of skill or knowledge. It serves our patients poorly and the clinical oversight of our work becomes a pointless exercise. This is especially the case where we are insufficiently trained to complete the necessary work. We cannot know what we don't know and therefore cast technicians must have an ongoing set of training objectives, with which to develop our knowledge and orthopaedic awareness.
The single course 'qualification' which constitutes today's TPMCS course is an unacceptable travesty of comprehensive training. It is not on all fours with the concept of lifelong learning. There are no different levels of understanding so that the certificate is issued to every cast technician, regardless of their knowledge, experience or skill set.
The TPMCS runs counter to cast technicians being able to demonstrate their knowledge, skills and experience to any clinician. There is no compulsion or incentive for the cast technician to improve their work or understanding after completing the TPMCS course. Many cast technicians fail to learn anything new. They manage to stay on the right side of 'qualified' by showing that they have some knowledge of the basic material which was offered to them on the only cast technician course which is available in the uk.
Advanced techniques, relevant discussion and further training are not offered in any way, shape or form. The AOP, OTA and BOA websites are devoid of any debate of the common clinical issues which may affect cast technicians and impinge on their clinical work. Dissenting opinions which had appeared on the web pages of the OTA and the AOP have been closed down. History has been rewritten by those who own those tightly controlled web pages; which could (and rightfully should) be used to serve and to educate cast technicians.
Any trace of rational debate has been expunged. Potentially interested parties then lost interest in trying to bring any technical debate to the online cast technician fraternity. Where the subject matter was not approved, it was never posted for all to share and discuss.
The use of semi-official cast technician sites (supposedly our professional web pages) as doorways into what are merely social media exchanges is to be deplored. These highly damaging and inconsequential social exchanges give the impression that cast technicians are not actually working as professional staff. Furthermore, it appears to be the case that we are uninterested in trying to bring about any changes which may be seen as for the good of our patients.
The status quo remains unchallenged. What indicators can be discerned which demonstrate that cast technicians form part of a vibrant and professional community? How are cast technicians moving towards raising our own standards? What further relevant courses of instruction are offered to TPMCS course certificate holders?
Are there likely to be any benefits to cast technicians, should we decide that we must improve our professional status among the clinicians and patients for whom we work? How might we improve our professional standing within the medical community? The pay ranges which I have seen used for cast technicians stretch from band 2 all the way to band 7. Most often, I see TPMCS certificate holders, who are usually drawn from the ranks of healthcare assistants, being paid at bands 2 and 3.
The responsibilities inherent in the work of the cast technician (acting as the clinician's proxy hands) are many and varied. What is unclear is why the essential and requisite skills are not being taught to cast technicians. Why is the TPMCS course focussed mainly on practical cast application? Why is the TPMCS course largely unchanged from the original Royal College of Nursing/Society of Orthopaedic Nursing British Casting Certificate (BCC) offered over four decades ago to nurses who belonged to the Society of Orthopaedic Nursing?
Why are TPMCS candidates/trainees frightened out of asking questions (by current holders of the TPMCS/BCC) who tell the potential students not to ask questions? Ostensibly this is because once the candidate arrives at the Royal National Orthopaedic Hospital, Stanmore (RNOH) or Bradford Royal Infirmary (BRI), they will have to assimilate the course material (read this as just do what they are told) and are made aware that they will not pass the course if they do not do exactly as they are instructed. Why do we need clones of the current crop of course tutors? These are the same tutors who have not advanced the training one iota since it began. Why is intelligent clinical judgement for TPMCS course candidates not encouraged?
The current TPMCS/BCC holders seem to think that they must prevent cast technician trainees from thinking for themselves. This level of stupidity would not be welcome in any profession. The TPMCS training course expects the 'qualified' cast technician to act as an independent practitioner according to this BOA webpage. The tutors of the TPMCS course must examine why they think it is desirable for all of their past students to only think in the patterns which have been approved by TPMCS course providers.
I used to think that the BCC/TPMCS course was moribund but salvageable. It would require the will of the course providers to change their emphasis. Cast technicians would need to see concrete evidence of a change. There must be some very clear thinking along with a complete re-orientation to a comprehensive and more appropriate and advanced course of instruction.
My thinking was that a concerted move, towards a substantially changed TPMCS course, would prepare cast technician course candidates for a clinical profession that was both widely recognised and respected.
The newly recognised profession (after a substantially reconstructed and lengthened course) would then contribute positively to the orthopaedic care of our patients. Cast technicians would go on to document and develop a body of knowledge concerning our work.
The documentation would stand as a resource for all future generations of trainee cast technicians. We would assemble, construct and provide advanced modules of training that would equip us all to work in a coherent, rational and recognised manner.
The casting work emanating from (BRI) and RNOH, Stanmore is not fit for purpose. The poor quality of clinical work taken in conjunction with the low technical standards which are apparently acceptable, have ensured that I no longer consider our cast technician certificated graduates, to be an exemplar of orthopaedic clinical practice.
The BOA should be examining what it requires from the numerous cast technician personnel working in the UK. It should be aware that its 'hands off' policy has permitted the training of cast technicians to become virtually worthless. Allowing the training of cast technicians to languish and reside in its present rut of inactivity for four decades, has had the unwanted effect on cast technician training of making it stand still and fail to keep pace with the progress made in other clinical areas.
The course of training has remained static and it has not gained any national recognition nor is it mandated. Why not? The TPMCS does not encourage cast technicians to work towards excellence in clinical practice. There ought to be a number of grades available; which would encourage TPMCS certificate holders to push themselves to greater heights of clinical participation.
Absent any clear guidance, the BOA should now permit the globally accepted Association for Osteosynthesis - Arbeitsgemeinschaft für Osteosynthesefragen (AO) organisation to state what the required skill level and knowledge of a cast technician ought to be. AOTrauma have made explicit the methods and rationale of casting and splinting treatment.
The guidance was published in December 2014 and it is a comprehensive, erudite, well-researched book written by by multiple authors. It was published by Thieme in December 2014 and it deserves to be on the shelf of every cast room in the UK. https://www.thieme.co.uk/casts-splints-and-support-bandages It would be an excellent starting point for any proposed standard of casting work.
The content of a cast technician course will depend on the time available to the student and the course organisers. The number of skills and the amount of knowledge required for a basic cast technician qualification (working in a cast room while being supervised) will determine how much time would be allocated to the transfer of knowledge from the tutors to the students.
Why do we need any course of instruction? The primary work which is undertaken by cast technicians is the splinting of limbs which have sustained injury because of acute trauma. The injuries span a range from simple, closed and extra-articular single fractures to multiple, open and complex intra-articular fractures.
The structures which are involved may be bones, joints, nerves, blood vessels, muscles, ligaments and skin. The normal bio-mechanical functions of the limb may have become disrupted to a greater or lesser degree.
The patient may have significant co-morbidities which inhibit or change the pattern of healing. The mobility of the patient may be impaired and this can have a significant effect on how we treat them. The patient may be an adult, a child, a neonate and they may possibly have appreciable learning difficulties.
The use of radiographic evidence to guide our casting work is an essential skill. The cast technician must be taught how to read and interpret plain radiographs of the appendicular skeleton. Arriving at sound clinical decisions based upon current best clinical practices is a skill which is developed by the practical application of known orthopaedic principles.
The serial splinting of paediatric patients with developmental dysplasia of the hip, idiopathic scoliosis, congenital talipes equino-varus and idiopathic toe-walking are also essential skills for the cast technician.
Acute fracture reduction and splinting for joints which have become dislocated (in addition to being fractured) is a skill which is required within the emergency department environment. Cast technicians are often called to assist with the splinting of acute trauma cases where significant structure disruption is a feature of the case.
The application of splints and orthoses is another area which may require cast technician input. The care of spatial frames, external fixators, kirchner wires, surgical or traumatic wounds are regular work expectations of cast technicians.
An understanding of the normal functioning of joints and limbs will enhance the work of the cast technician. Walking aid issue and fitting will permit the cast technician to underpin the care delivered in the cast room, with sound and safe support of an injured limb.
Being able to identify early deformities such as a fixed flexion deformity of the fingers, or an incipient complex regional pain syndrome, are essential abilities for a cast technician. Knowing what the normal ranges of movement are for joints and how to use a goniometer are skills which assist cast technicians with identifying problems early in the healing cycle.
Knowing how to write clinical records in a meaningful manner and documenting all instances of treatment in the patient's clinical care record is an essential skill. It is frequently poorly completed therefore a reasonable conclusion is that it is poorly taught.
Anatomical knowledge must be used to accurately describe injury patterns, type and location. This work requires the cast technician to understand the specific orthopaedic terminology that is used by clinicians.
Close moulding of every cast requires far more technical understanding than is provided by the current short course. Without an understanding of the rationale behind the careful alignment and apposition of fracture fragments, the application of the cast becomes a mindless exercise in window dressing. That is to say if it appears to the patient as if a treatment has been applied then it will be deemed to be suitable.
The foregoing is a small non-exhaustive list of some of the reasons why it is important for a specifically technical course to be developed for cast technicians. The course must equip the newly qualified cast technician to work in the environment which will regularly test their clinical skills to the limit. The application of the cast is probably the easiest task for them to complete.
The peripheral factors which must be accounted for by a competent cast technician are far more likely to influence the success of the treatment prescription than the actual cast application. The low technical quality of the work produced by many TPMCS holders is evidence that the course is not achieving what it sets out to provide... an acceptable national standard of work for cast and splint application.
How can it be that after four decades of existence, the TPMCS course is not a mandatory requirement? I would suggest that the low level of instruction, the variable standards of work and the unknown level of knowledge provided, are contributing factors to the low regard in which the course appears to be held.
The failure of the TPMCS course certificate holders to be recognised by the Health and Care Professions Council is further evidence of the low esteem with which official registration bodies regard the British Casting Certificate. The course organisers have prevaricated and sidestepped this issue for far too long.
On the evidence available, it is reasonable to conclude that the course is located in completely the wrong work space. The TPMCS does not teach sufficient material at any suitable higher level of training. Nor does it require its candidates to understand the work which they will be called upon to undertake.
Proposed Course Materials
Anatomy - An understanding of basic anatomy is essential. It will assist the cast technician student to recognise the normal anatomy and be able to differentiate it from the abnormal anatomy found in traumatic injuries and developmental variations.
The anatomical location of any particular feature is essential for accurate clinical record keeping. Anatomical accuracy requires a knowledge of gross anatomy, surface anatomy, neurological and vascular anatomy. Systems of fracture classification such as the AO system which do not rely on eponymous descriptors will also require learning and assimilation.
There is the requirement to understand the relative anatomical positions of the muscles and ligaments and how they affect normal movement. The impact of any injury upon the normal biomechanical movements of the limbs cannot be understood without a clear understanding of anatomy.
Joints and Their Functions
The normal ranges of movement of the joints and their functions should be taught to cast technician trainees. We may be the first to see problems during healing; when casting and recasting injured limbs.
Without a knowledge of the normal functions of joints, cast technicians may allow a developing issue to become worse. The use of a goniometer is an essential skill so that evidential quality clinical record-keeping can be completed as a part of the normal duties of a cast technician.
The sensory and motor functions of the neurological system are an integral part of how the joints are moved. The anatomical positions of the nerves, along with the signs and symptoms of major neurological malfunctions and significant nerve disruptions, should also be taught to trainee cast technicians.
The movement of the limbs cannot be addressed without examining and learning about the biomechanics of movement. Normal movement and the issues which impinge upon it should be taught as an integral part of any course on limb trauma.
The study of the deformation forces which cause fractures to occur, and the resulting fracture patterns caused by these forces, will prepare the trainee cast technician to understand how to correct the radiographic image of the injuries sustained. The AO handbook concerning the principles of non-operative fracture treatment is a suitable starting point for these lessons.
Developmental conditions in children should be included in the basic course for cast technicians. This will help the trainees to recognise the common conditions and to know when expert intervention is required. The application of EDF jackets, hip spicas, Ponseti and serial casts for idiopathic conditions such as toe walking all require a high level of knowledge, skill and experience.
Cast technician trainees (and recently certificated cast technicians) must be taught how to recognise these developmental conditions and then to know that the treatments are significant and beyond their knowledge and ability to apply correctly. The incorrect handling of paediatric patients is an impediment to applying essential treatments and some time should be devoted to working with children on the basic course.
The rudiments of orthopaedic clinical examination should be taught to cast technician trainees to enable them to confirm any suspicions; where a treatment does not appear to be progressing as expected. There are a number of useful books which can aid the understanding of a cast technician in this respect. I recommend a book along the lines of Bones and Joints - a guide for students by Chris Gunn.
Special Tests in Musculoskeletal Examination by Paul Hattam and Alison Smeatham is an invaluable insight into evidence based tests. The tests have been described and conducted with a view to reference standards, sensitivity, specificity and validity. This valuable book is a helpful introduction to examining a limb or joint that is not functioning correctly. It represents advanced clinical practice but will serve to introduce the trainee cast technician to the difficulties inherent in trying to determine whether a problem actually exists.
Wound care is an integral part of the work of a cast technician. The current standard is the ANTT package which is accepted and taught widely within the NHS organisations where the care of wounds is part of the treatment. The wide acceptance of the use of standard and surgical ANTT methods has provided a common standard with which all staff are expected to work. ANTT should be specifically taught on the training course for cast technicians.
The positioning of injured limbs during casting treatment and the maintenance of patient comfort is vital knowledge especially where iatrogenic harm is to be avoided. Severely injured patients present challenges which cast technicians must address when the work demands it.
Complicated and open fractures usually demand that a cast technician will provide some creative means of limb and patient support. The use of gravity combined with anatomical functions will frequently and satisfactorily address the casting needs of complex injuries.
Humeral Fracture Management
The management of humeral fractures is frequently unsatisfactory. The tuition of clinically sound and reproducible stabilisation methods is another essential skill for cast technicians. This particular fracture is often seen in the elderly patient and it does not appear to be treated with any degree of certainty.
Interpreting radiographic information which accompanies each traumatic injury is an essential skill for cast technicians and it should be taught formally. A radiologist's report may explain what the trauma has damaged but the visual representation is what guides the cast technician's hands.
My recommendation is for all cast technicians to undertake the listed course of trauma radiographic interpretation of the appendicular skeleton; it can be found on the pages of Radiology Masterclass. It is my considered opinion that you will be hard put to find a more coherent and useful set of trauma radiology interpretation instructional pages than these.
The course is relatively cheap at £82 and the certificate gained is valid for three years and it is electronically verifiable, while being worth 5 CPD points. The course is approved by the Royal College of Radiologists.
The provision of walking aids is an integral part of the work of a cast technician. We commonly have to provide patients with crutches and walking frames. Many patients may be seen struggling to mobilise because they have had no instruction in the use of their provided walking aids.
Cast technicians need specific tuition in how to measure, fit, issue and instruct patients in the use of walking aids. Additionally, they must recognise when specialist walking aids and tuition are required.
Fracture Reduction Methods
These methods will be used in patients with acute trauma. The reductions will be required when the soft tissues are at their most vulnerable and great care will be needed to secure a reduction of the fracture fragments. The application of temporary POP splints must account for the fact that they are being applied as the start of a formal orthopaedic treatment rather than the end of an A&E department emergency treatment.
Orthoses and Splint Fitting
The fitting of fixed walking boots, splints for forearm injuries such as a futuro splint. AFOs and Aircast boots are also fitted by a cast technician in many institutions. Creating splints that are removable and serve a specific purpose.
Clinical Observations and Record Keeping
The recording of relevant clinical observations and the manner in which those records are written, is an essential skill for cast technicians. All treatments have to be recorded accurately so that the work can be logged.
Metalwork Adjustment and Removal
The removal of Kirchner wires and external fixators is an integral part of the work of cast technicians. This work may also include the cleaning of pin sites in trauma and the adjustment of spatial frames for cases such as distraction osteogenesis.
Knowledge of the common microorganisms and commensals. Prevention of cross infection and aseptic techniques for wound care and dressings. Knowledge of tissue viability methods and techniques and the various dressings by which means wound care may be effected. Knowledge of the European Pressure Ulcer Advisory Panel quick reference guide will help the cast technician to alert other staff to incipient ulcer formation.
Physiotherapeutic Methods for Maintaining Joint Mobility
The knowledge of basic physiotherapeutic methods for ensuring that the joints of patients do not become stiff and immobile. Musculoskeletal physiotherapy techniques can include many different types of practice. It should be sufficient for the cast technician to learn how to keep joints mobile via simple passive movements and exercise demonstrations.
Functional Cast Bracing
This relies on the cast technician constructing a cast which provides the patient with functional movement. The cast provided must be a perfect fit and permit the attachment of hinges to allow movement in all of the usual planes. Commonly cast are elbow joints, wrist joints, knee joints and less commonly ankle joints.
Pain management at the time of an initial cast application, and later on during the healing cycle, is a necessary work function of the cast technician. To apply or remove a cast while inflicting pain upon the patient is very poor care.
Cast technicians will see fracture reductions of wrist injuries carried out using a haematoma block in the emergency department or the use of Nitrous Oxide gas (Entonox) within the cast room. One useful cast room addition is a Chinese finger trap for effective joint stabilisation and pain relief.
The care of children also raises the issue of pain. I have seen cast rooms which have a policy of removing Kirchner wires from relatively young children, within the plaster room. Although some supracondylar fractures may be amenable to wire removal after three or four weeks in situ, the method is quite likely to provide young children with a traumatic experience.
Recognising when analgesia is a pre-requisite of cast room treatment is an essential skill for cast technicians. Post surgery and complex trauma cases are likely to require analgesic cover and they should receive it in a timely manner before they are sent to the cast room. One useful an possibly essential part of pain management is for the patient to be accompanied by a friend or a relative. In every case, the patient's complaints of pain should be noted and always addressed at the time.
Clinical Record Recording
The ability to accurately and professionally record all episodes of patient contact has to be taught. The use of computer systems has had an effect on the amount and type of text which can be entered into a computer system. The imperative to drop paper records has also seen changes in the way that clinical care episodes are recorded. All cast technicians should be aware of what and how to record each clinical contact with the patient.
Clinical Research Method
It is apparent that clinical research is not being carried out by cast technicians in the UK. This is one of the principle ways in which we can establish problem areas for other cast technicians and then propose the solutions. It is imperative that clinical research is viewed as an integral part of the responsible cast technician's employment role, and to that end, it must be included in any training programme which is proposed.
Practical Skills Audit
This is the means by which active and practising cast technicians can ascertain which skills they have used and which skills they lack. The skills audit is a means by which skills can be improved and a running assessment can be used to help fix the skills at a high level. Cast technicians should be taught how to assess and evaluate their own skill levels and usage.
Plaster Room Risk Assessment and Method Statement Writing
These two skills are essential in the pursuit of a safe working environment for staff and patients. Cast technicians should be aware of how to tackle these two tasks.
This skill requires the cast technician to be able to assess and validate the findings of their research into various pieces of equipment or stock which they wish to use. Making a business case for the use of a product may save NHS Trusts vast sums of money. Procurement and assessment of the items for use in the cast room, is a skill which cast technicians should possess before running their own plaster room.
Cast Care Instructions
Cast technicians should recognise how to phrase cast care instructions. They must know when the verbiage is excessive or contains too much jargon. They should be aware of translation services and have a plan in place for dyslexic people and people who cannot speak English. The provision of instructions to patients should be taught on a basic cast technician course. No patient should leave the cast room and be in doubt about how to care for their injured limb in a cast.
The foregoing represents the minimum amount of knowledge which should be imparted to cast technician trainees. It must be clear that five weeks will not permit adequate time for the learning process to become complete. It must also be clear that what has been listed above, falls a very long way short of that which is offered by professional bodies such as the CSOT.
Our expectations of the cast technician candidates must be raised by a considerable amount. Our tuition standards must be raised to include everything which we have come to expect of the cast technician. Our knowledge, skills and experience must be elevated to a point where the clinicians and patients (for whom we work) can see that they can trust us to do the best job of work possible. We cannot permit the training of cast technicians to fall below its current unacceptable nadir.
It is long past the time when the leaders of our profession should have addressed this urgent and pressing issue. Now; they should abandon it and give it up to an organisation that will do everything it can to improve the lamentable situation in which the cast technicians of the UK find ourselves.